Mike Fischer RMT

                                            Confidential Patient Case History

Name:__________________________________________________________________

Address: ______________________________________________ Postal Code: _______

Email address:   ___________________________________________________________

How Did You Hear About Our Clinic:  ________________________________________

Home Phone #: ________________ Work #: ________________ Cell #:  _____________

Employer: ___________________________________ Position:  ___________________

Male/Female.  Birth Date: __________ Age: _____

# of Children _____  Ages of Children _________________________________________

Comments / Notes of Caution Chief Complaint: ____________________

__________________________________    ____________________________________

__________________________________    ____________________________________

__________________________________    Initial Onset: _______________________

__________________________________    Probable Cause: _____________________

__________________________________    Acute / Chronic

Hobbies, Sports or Recreation:

________________________________________________________________________

Have you ever had massage before? YES / NO. Where? _________________________

Date of last treatment: _____________________________________________________

What are your goals and expectations from this session? ________________________________________________________________________

Who is your Family Doctor? ________________________________________________

Have you been for any of the following treatments in the last 12 months?

ChiropracticYES / NO Who? ____________________________________

Physiotherapy YES / NO  Who? ____________________________________

Conditioning Therapy YES / NO Acupuncture YES / NO

1. Have you had any serious falls, motor vehicle accidents, surgeries or injuries?

YES / NO

Explain and include dates: ________________________________________________

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

4. Is your Blood Pressure: Normal High Low Stable Erratic

_____________________________________________________________________

5. Have you ever been treated for? If YES, please explain

any psychological or emotional health issues YES / NO _________________________

thyroid problems YES / NO _________________________

ulcers YES / NO _________________________

heart disease YES / NO _________________________

lung disease YES / NO _________________________

cancer YES / NO _________________________

diabetes YES / NO _________________________

HIV / Immune Deficiency YES / NO _________________________

arthritis YES / NO _________________________

fibromyalgia YES / NO _________________________

liver disorder / hepatitis YES / NO _________________________

blood clots / varicose veins YES / NO _________________________

TMJ YES / NO _________________________

dizziness YES / NO _________________________

other medical conditions or concerns: _____________________________________________

____________________________________________________________________________________

7. Please circle:

Sleep: How many hours per nightNone 1 – 3    3 – 5     5 – 10     More

Exercise: How many hours per weekNone 1 – 3    3 – 5     5 – 10     More

Water Consumption: How many glasses per day None 1 – 3    3 – 5     5 – 10     More

Coffee: How many cups per day None 1 – 3    3 – 5     5 – 10     More

Alcohol: How many drinks per week None 1 – 3    3 – 5     5 – 10     More

Smoking: How many packs per day None > 1/2 pkg   1/2 pkg   full pkg   More

Headache and Migraine History:

Do you get?  (please circle) Headaches / Migraines / Both

How often do you get them? ________________________________________________

How long do they last? ____________________________________________________

What causes your headaches? _______________________________________________

What do you take to control them? ___________________________________________

Current Medications

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

CANCELLATION POLICY

I understand that I must give 24 hours notice when canceling an appointment or will be charged in full if the

appointment is not filled. By my signature below, I authorize the collection, use and disclosure of personal

information, as defined in the Personal Information and Protection Act (PIPA), required for treatment

and/or any related administrative purpose. I understand that all my personal information is confidential, and

must be treated in accordance with PIPA.

Signature:__________________________________________Date:________________